Pilot randomised controlled trial of a brief mindfulness-based intervention for those with persistent pain.

A pilot-randomised controlled trial (RCT) examined the effects of a brief mindfulness-based intervention (MBI) on persistent pain patients and assessed the feasibility of conducting a definitive RCT. A brief (15 min) mindfulness body-scan audio was compared with an active control administered in a clinic and then used independently over 1 month. Immediate effects of the intervention were assessed with brief measures of pain severity, distraction and distress. Assessments at baseline, 1 week and 1 month included pain severity and interference, mood, pain-catastrophizing, mindfulness, self-efficacy, quality of life and intervention acceptability. Of 220 referred patients, 147 were randomised and 71 completed all assessments. There were no significant immediate intervention effects. There were significant positive effects for ratings of intervention 'usefulness' at 1 week (p = 0.044), and pain self-efficacy at 1 month (p = 0.039) for the MBI group compared with control. Evidently, it is feasible to recruit persistent pain patients to a brief MBI study. Strategies are needed to maximise retention of participants.Trial registration Current controlled trials ISRCTN61538090. Registered 20 April 2015.

Feasibility study to assess the effect of a brief mindfulness intervention for patients with chronic obstructive pulmonary disease: A randomized controlled trial.

Psychological distress is common among patients with chronic obstructive pulmonary disease (COPD). This study aimed to assess whether a 10-minute mindfulness intervention reduces distress and breathlessness, improves mood and increases mindfulness among hospital inpatients following acute exacerbation of COPD.Fifty patients were recruited following an acute admission. The immediate effects of a 10-minute mindfulness-based body scan were compared with a control intervention. Participants were randomized to receive either a mindfulness-based body scan ( n = 24) or a control condition ( n = 26) via a 10-minute audio recording. Participants completed a self-assessment survey, including the Borg scale for breathlessness, Philadelphia Mindfulness Scale and Hospital Anxiety and Depression Scale. They then completed six brief single item measures of dyspnoea, anxiety, depression, happiness, stress and mindfulness before and after the intervention daily for three consecutive days. Acceptability was rated according to 'usefulness' and whether they would recommend the intervention to other patients. Results showed that there was a tendency for change in most outcomes, but no significant differences between the groups. Most participants rated the intervention as useful and would recommend it. Existing knowledge of mindfulness interventions among these patients is very limited and this study may be helpful in the development of other brief interventions.

Coping With Staff Burnout and Work-Related Posttraumatic Stress in Intensive Care.

OBJECTIVES: To examine the associations with symptoms of 1) burnout and 2) work-related posttraumatic stress, in adult and pediatric intensive care staff, focusing on the particular contributions of resilience and coping strategies. DESIGN: Point prevalence cross-sectional study. SETTING: Three adult ICUs and four PICUs. SUBJECTS: Three hundred seventy-seven ICU staff. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Brief Resilience Scale, abbreviated Maslach Burnout Inventory, Trauma Screening Questionnaire, and Hospital Anxiety and Depression Scale. Prevalence of burnout (defined as high emotional exhaustion or high depersonalization) was 37%. Prevalence of clinically significant posttraumatic stress symptoms was 13%. There was a degree of overlap between burnout and other measures of distress, most notably for anxiety (odds ratio, 10.56; 95% CI, 4.12-27.02; p < 0.001). Hierarchical logistic regression demonstrated that self-reported resilience was strongly associated with decreased likelihood of meeting criteria for both forms of work-related distress (burnout: odds ratio, 0.52; 95% CI, 0.36-0.74; p < 0.001 and posttraumatic stress: odds ratio, 0.28; 95% CI, 0.16-0.46; p < 0.001) and that physicians were twice as likely as nurses to be at risk of reporting burnout (odds ratio, 2.11; 95% CI, 1.18-3.78; p = 0.012). After controlling for resilience, profession, and setting, the following coping strategies were independently associated with outcomes: attending debriefing reduced risk of burnout (odds ratio, 0.45; 95% CI, 0.21-0.95; p = 0.036), whereas the odds of posttraumatic stress were less if staff used talking to seniors (odds ratio, 0.43; 95% CI, 0.20-0.92; p = 0.029) or hobbies (odds ratio, 0.46; 95% CI, 0.23-0.93; p = 0.030) to cope with stress at work. Venting emotion (odds ratio, 1.92; 95% CI, 1.12-3.31; p = 0.018) and using alcohol (odds ratio, 2.30; 95% CI, 1.26-4.20; p = 0.006) were associated with a doubling in risk of reporting burnout. CONCLUSIONS: The use of particular coping strategies was systematically associated with symptoms of burnout and work-related posttraumatic stress in this group of intensive care staff, even after controlling for resilience and other factors. More research on how best to promote adaptive coping is needed in these challenging settings.

Views on a brief mindfulness intervention among patients with long-term illness.

BACKGROUND: Chronic illness is the leading cause of death in the UK and worldwide. Psychological therapies to support self-management have been shown to play an important role in helping those with chronic illness cope; more recently, the therapeutic benefits of mindfulness approaches have become evident for managing depression and other distressing emotions. Brief guided mindfulness interventions, are more convenient than intensive traditional programmes requiring regular attendance but have been less explored. This study assessed views on a brief (i.e., 10 min) mindfulness intervention for those with specific long-term illnesses. METHODS: Semi-structured interviews and focus groups were conducted with chronic illness patient groups (i.e., chronic obstructive pulmonary disease, chronic pain and cardiovascular disease), designed to capture the acceptability and feasibility of the intervention. The interviews were conducted after use of a mindfulness based audio in clinic and, one week later, after use in the patient's own environment. Interviews were recorded, transcribed and analysed using thematic analysis. RESULTS: In total, a combination of 18 interviews and focus groups were conducted among 14 patients. Recruitment was most successful with chronic pain patients. All patients reported benefits such as feelings of relaxation and improved coping with symptoms. While the wording and content of the audio were generally well received, it was suggested that the length could be increased, as it felt rushed, and that more guidance about the purpose of mindfulness, and when to use it, was needed. CONCLUSIONS: A brief mindfulness intervention was well accepted among patients with long-term illness. The intervention may benefit by being lengthened and by offering further guidance on its use.

Pilot study evaluating a brief mindfulness intervention for those with chronic pain: study protocol for a randomized controlled trial.

BACKGROUND: The burden of chronic pain is a major challenge, impacting the quality of life of patients. Intensive programmes of mindfulness-based therapy can help patients to cope with chronic pain but can be time consuming and require a trained specialist to implement. The self-management model of care is now integral to the care of patients with chronic pain; home-based interventions can be very acceptable, making a compelling argument for investigating brief, self-management interventions. The aim of this study is two-fold: to assess the immediate effects of a brief self-help mindfulness intervention for coping with chronic pain and to assess the feasibility of conducting a definitive randomized controlled trial to determine the effectiveness of such an intervention. METHODS/DESIGN: A randomized controlled pilot study will be conducted to evaluate a brief mindfulness intervention for those with chronic pain. Ninety chronic pain patients who attend hospital outpatient clinics will be recruited and allocated randomly to either the control or treatment group on a 1:1 basis using the computer-generated list of random numbers. The treatment group receives mindfulness audios and the control group receives audios of readings from a non-fiction book, all of which are 15 minutes in length. Immediate effects of the intervention are assessed with brief psychological measures immediately before and after audio use. Mindfulness, mood, health-related quality of life, pain catastrophizing and experience of the intervention are assessed with standardized measures, brief ratings and brief telephone follow-ups, at baseline and after one week and one month. Feasibility is assessed by estimation of effect sizes for outcomes, patient adherence and experience, and appraisal of resource allocation in provision of the intervention. DISCUSSION: This trial will assess whether a brief mindfulness-based intervention is effective for immediately reducing perceived distress and pain with the side effect of increasing relaxation in chronic pain patients and will determine the feasibility of conducting a definitive randomized controlled trial. Patient recruitment began in January 2015 and is due to be completed in June 2016. TRIAL REGISTRATION: ISRCTN61538090 Registered 20 April 2015.

Reporting of Posttraumatic Stress Disorder and Cardiac Misconceptions Following Cardiac Rehabilitation.

PURPOSE: Approximately 15% of cardiac patients experience posttraumatic stress disorder (PTSD), double the incidence seen in the general community. Posttraumatic stress disorder can seriously affect psychological and physical recovery. This study assessed how many patients reported symptoms of PTSD following a cardiac event and examined whether there was any change after completing a cardiac rehabilitation (CR) program. Associations between PTSD and anxiety, depression, and cardiac misconceptions were also explored. METHODS: This was a prospective cohort study using repeated measures. All patients eligible for the hospital CR program were invited to complete questionnaires assessing psychological distress and beliefs about heart disease before (T1) and after (T2) completing the CR program. RESULTS: Questionnaires at T1 were returned by 105 patients. Of these, 24% reported symptoms of PTSD, 18% high anxiety, and 9% high levels of depression. At T2, 67 patients returned questionnaires, showing that 9% of patients continued to experience PTSD. These patients experienced significantly higher levels of anxiety (t = -4.77; P < .001) and depression (t = -3.64; P < .001). Intrusive thoughts and hyperarousal were significantly lower at T2 (t = 2.32; P = .02 and t = 3.01; P = .01, respectively). More misconceptions were associated with higher levels of anxiety and depression; however, the number of cardiac misconceptions remained similar throughout. Caucasians reported significantly fewer misconceptions than non-Caucasian patients, except for beliefs about myocardial infarction. Patients had fewer misconceptions about their own specific condition. CONCLUSIONS: These findings suggest that screening for symptoms of PTSD after completion of a CR program would be helpful in identifying patients who would benefit from specialist psychological support.

Intentional and unintentional non-adherence to medications following an acute coronary syndrome: a longitudinal study.

OBJECTIVE: Non-adherence to medication is common among coronary heart disease patients. Non-adherence to medication may be either intentional or unintentional. In this analysis we provide estimates of intentional and unintentional non-adherence in the year following an acute coronary syndrome (ACS). METHOD: In this descriptive prospective observational study of patients with confirmed ACS medication adherence measures were derived from responses to the Medication Adherence Report Scale at approximately 2 weeks (n=223), 6 months (n=139) and 12 months (n=136) following discharge from acute treatment for ACS. RESULTS: Total medication non-adherence was 20%, 54% and 53% at each of these time points respectively. The corresponding figures for intentional non-adherence were 8%, 15% and 15% and 15%, 52% and 53% for unintentional non-adherence. There were significant increases in the levels of medication non-adherence between the immediate discharge period (2 weeks) and 6 months that appeared to stabilize between 6 and 12 months after acute treatment for ACS. CONCLUSION: Unintentional non-adherence to medications may be the primary form of non-adherence in the year following ACS. Interventions delivered early in the post-discharge period may prevent the relatively high levels of non-adherence that appear to become established by 6 months following an ACS.

Symptom experience during acute coronary syndrome and the development of posttraumatic stress symptoms.

There is growing evidence for the development of posttraumatic stress symptoms as a consequence of acute cardiac events. Acute coronary syndrome (ACS) patients experience a range of acute cardiac symptoms, and these may cluster together in specific patterns. The objectives of this study were to establish distinct symptom clusters in ACS patients, and to investigate whether the experience of different types of symptom clusters are associated with posttraumatic symptom intensity at six months. ACS patients were interviewed in hospital within 48 h of admission, 294 patients provided information on symptoms before hospitalisation, and cluster analysis was used to identify patterns. Posttraumatic stress symptoms were assessed in 156 patients at six months. Three symptom clusters were identified; pain symptoms, diffuse symptoms and symptoms of dyspnea. In multiple regression analyses, adjusting for sociodemographic, clinical and psychological factors, the pain symptoms cluster (ß = .153, P = .044) emerged as a significant predictor of posttraumatic symptom severity at six months. A marginally significant association was observed between symptoms of dyspnea and reduced intrusive symptoms at six months (ß = -.156, P = .061). Findings suggest acute ACS symptoms occur in distinct clusters, which may have distinctive effects on intensity of subsequent posttraumatic symptoms. Since posttraumatic stress is associated with adverse outcomes, identifying patients at risk based on their symptom experience during ACS may be useful in targeting interventions.

Type D personality, self-efficacy, and medication adherence following an acute coronary syndrome.

OBJECTIVE: To assess the relationship among Type D personality, self-efficacy, and medication adherence in patients with coronary heart disease. METHODS: The study design was prospective and observational. Type D personality, self-efficacy for illness management behaviors, and medication adherence were measured 3 weeks after hospitalization for acute coronary syndrome in 165 patients (mean [standard deviation] age = 61.62 [10.61] years, 16% women). Self-reported medication adherence was measured 6 months later in 118 of these patients. Multiple linear regression and mediation analyses were used to address the study research questions. RESULTS: Using the original categorical classification, 30% of patients with acute coronary syndrome were classified as having Type D personality. Categorically defined patients with Type D personality had significantly poorer medication adherence at 6 months (r = -0.29, p < .01). Negative affectivity (NA; r = -0.25, p = .01) and social inhibition (r = -0.19, p = .04), the components of Type D personality, were associated with medication adherence 6 months after discharge in bivariate analyses. There was no evidence for the interaction of NA and social inhibition, that is, Type D personality, in the prediction of medication adherence 6 months after discharge in multivariate analysis. The observed association between NA and medication adherence 6 months after discharge could be partly explained by indirect effects through self-efficacy in mediation analysis (coefficient = -0.012; 95% bias-corrected and accelerated confidence interval = -0.036 to -0.001). CONCLUSIONS: The present data suggest the primacy of NA over the Type D personality construct in predicting medication adherence. Lower levels of self-efficacy may be a mediator between higher levels of NA and poor adherence to medication in patients with coronary heart disease.

Fear of dying and inflammation following acute coronary syndrome.

AIMS: Many patients are afraid of dying during acute coronary syndrome (ACS), but the origins and biological correlates of these emotional responses are poorly understood. This study evaluated the prevalence of fear of dying, associations with inflammatory responses during ACS, and later heart rate variability (HRV) and cortisol secretion. METHODS AND RESULTS: Two hundred and eight patients admitted with clinically verified ACS rated their fear of dying on interview in hospital. Plasma tumour necrosis factor (TNF)α was recorded on admission, and HRV and salivary cortisol were assessed 3 weeks later. Intense distress and fear of dying was experienced by 21.7%, with moderate levels in 66.1% patients. Fear of dying was more common in younger, lower socioeconomic status, and unmarried patients. It was positively associated with plasma TNFα on admission after controlling for sociodemographic factors, clinical risk, and pain intensity (adjusted odds = 4.67, 95% C.I. 1.66-12.65). TNFα was associated with reduced HRV 3 weeks later, adjusting for clinical and sociodemographic factors and medication (P = 0.019), while fear of dying was associated with reduced cortisol output (P = 0.004). CONCLUSIONS: Intense distress and fear of dying and heightened inflammation may be related manifestations of an acute biobehavioural response to severe cardiac injury, and have implications for prognostically significant biological risk processes.

The long-term effects of acute triggers of acute coronary syndromes on adaptation and quality of life.

BACKGROUND: A proportion of acute coronary syndromes (ACS) are thought to be triggered acutely by physical exertion, emotional stress and other stimuli. We assessed the consequences of triggering for long-term adaptation following ACS. METHODS: We assessed mental and physical health status in 150 male and 44 female ACS survivors 12 and 36 months after cardiac events using standardised questionnaire measures. Triggers were assessed by interview an average of 2.56 days after hospital admission. Emotional triggers were defined as moderate or intense anger, stress or sadness/depressed mood in the 2 h before symptom onset, while vigorous physical exertion was defined as activity >/=6 metabolic equivalents in the hour before symptom onset. Clinical characteristics, psychiatric history, health behaviours and the Global Registry of Acute Coronary Events (Grace) risk algorithm were also assessed. RESULTS: Emotional triggers predicted elevated anxiety and poor mental health status at 12 months independently of age, gender, socioeconomic status, ACS presentation, Grace risk scores, pre-admission medication, anxiety in hospital, depression history and symptom recurrence (p<0.001). Effects persisted at 36 months. Emotional triggers were not related to physical health status at follow up. By contrast, impaired physical health status was predicted by vigorous exertion during the trigger period independently of covariates (p=0.019). CONCLUSIONS: ACS triggering has a long-term impact on adaptation and quality of life, with differential effects of physical and emotional triggers.

Pre-hospital delay in patients with acute coronary syndrome: factors associated with patient decision time and home-to-hospital delay.

BACKGROUND: Pre-hospital delays in patients experiencing acute coronary syndromes (ACS) remain unacceptably long. AIMS: To examine simultaneously a wide range of clinical, sociodemographic and situational factors associated with total pre-hospital delay and its two components. METHODS: Pre-hospital delay data were collected from 228 patients with ACS using patient's medical notes and semi-structured interviews. Total pre-hospital delay (symptom onset to hospital admission) was divided into 2 components: decision time (symptom onset to call for medical help), and home-to-hospital delay (call for help to hospital admission). RESULTS: Shorter total pre-hospital delays and decision times were associated with ST segment myocardial infarction (STEMI), recognizing symptoms as cardiac in origin, being married, symptom onset outside the home and the presence of a bystander. Shorter home-to-hospital delays were more likely among younger patients, those experiencing an STEMI, and patients reporting a greater number of symptoms. Initial contact with emergency medical services was related to shorter total delays and decision times. CONCLUSIONS: Different factors were associated with shorter times in the 2 component phases. Greater understanding of the factors impacting on the component phases may help target interventions more effectively and reduce pre-hospital delays.

Practical support predicts medication adherence and attendance at cardiac rehabilitation following acute coronary syndrome.

OBJECTIVE: Poor social support is associated with recurrent cardiac events following acute coronary syndrome (ACS). Interventions have largely targeted emotional support, but practical support may be particularly important in encouraging recovery behaviors. We assessed whether practical and emotional support differentially predicted medication adherence and rehabilitation attendance following ACS. METHODS: This prospective observational clinical cohort study involved 262 survivors of verified ACS, recruited from four coronary care units in the London area. Practical and emotional support were measured in hospital, and depression, 7-10 days after discharge. Medication adherence and rehabilitation attendance were assessed by telephone interview 12 months after hospitalization. RESULTS: Nearly one third of patients (29.8%) had no practical supports, 16% had one, and 54.2% had two or more sources of practical support. Patients with greater practical support were more likely to adhere to medication (P=.034) independently of age, gender, marital status, clinical risk profile, and depression. There was also an association with rehabilitation attendance (P=.034), but this was no longer significant after depression had been taken into account. Emotional support was unrelated to medication adherence and rehabilitation attendance. CONCLUSIONS: Cardiac patients with greater practical support may receive more prompts about medications, help with filling prescriptions and assistance with cardiac rehabilitation attendance. These behaviors can influence long-term recovery.

Causal beliefs, cardiac denial and pre-hospital delays following the onset of acute coronary syndromes.

Reducing pre-hospital delay is crucial in reducing mortality from acute coronary syndrome (ACS). Patient's causal beliefs and coping styles may affect symptom appraisal and help-seeking behavior. We examined whether patient's beliefs about the causes of their ACS and denial of impact were associated with pre-hospital delay. Pre-hospital delay data were collected from 177 patients with ACS. Retrospective causal beliefs and cardiac denial of impact were assessed using questionnaires. Factor analysis of causal beliefs produced 3 factors; beliefs in stress and emotional state, behavioral and clinical risk factors, and in heredity as causal influences. Patients with strong beliefs that stress and emotional state caused their ACS were more likely to have long pre-hospital delays (>130 min). There were no significant associations between pre-hospital delay and the other two causal belief factors. Patients with greater denial scores were also more likely to have long delays than those with low scores. These effects were independent of age, gender, education, previous myocardial infarction, history of depression and negative affectivity. Cognitive and emotional factors including patient's beliefs about causes and avoidant coping help to explain variations in pre-hospital delay.

Type-D personality and cortisol in survivors of acute coronary syndrome.

OBJECTIVE: To test the hypothesis that Type-D personality is associated with elevated cortisol levels in patients 4 months after an acute coronary syndrome (ACS). METHODS: Salivary cortisol profiles were measured at home in 70 coronary heart disease patients (Mean age = 60.90 years, SD = 10.7, 17% female) 4 months after hospitalization for ACS. Eight saliva samples were taken over the course of 1 day. RESULTS: Thirty eight percent of the ACS patients were defined as Type-D. Cortisol profiles showed a typical diurnal pattern, with low levels in the evening, high levels early in the day. Type-D was not related to the cortisol awakening response, but cortisol output the day was higher in Type-D (mean = 4443.3, SD = 2334.1 nmol/l) than non Type-D patients (mean = 3252.0, SD = 1810.2 nmol/l) after adjustment for age, gender, hypertension, Global Registry of Acute Coronary Events risk score, recurrence of cardiac symptoms, previous myocardial infarction, body mass index and concurrent depressed mood (p = .044). Type-D personality accounted for 6% over the variance in cortisol output over the day, after covariates had been taken into account. CONCLUSION: Type-D personality may be associated with prolonged disruption of the hypothalamic-pituitary-adrenal axis function in survivors of acute cardiac events and may contribute to biological responses influencing future cardiac morbidity.

Persistence of posttraumatic stress symptoms 12 and 36 months after acute coronary syndrome.

OBJECTIVES: To assess the prevalence and predictors of posttraumatic stress symptoms in patients at 12 and 36 months post hospital admission for an acute coronary syndrome (ACS). There is increasing recognition that posttraumatic stress may develop in the aftermath of an acute cardiac event. However, there has been little research on the longer-term prevalence of posttraumatic stress disorder (PTSD). METHODS: Posttraumatic stress symptoms were assessed at 12 months in 213 patients with ACS and in 179 patients at 36 months. Predictor variables included clinical, demographic, and emotional factors measured during hospital admission. RESULTS: At 12 months post ACS, 26 (12.2%) patients qualified for a diagnosis of PTSD; 23 (12.8%) patients were identified with PTSD at 36 months. Posttraumatic symptoms at 12 months were associated with younger age, ethnic minority status, social deprivation, cardiac symptom recurrence, history of depression, depressed mood during admission, hostility, and Type D personality. In multiple regression, depressed mood during admission and recurrent cardiac symptoms were independent predictors of posttraumatic symptoms (R(2) = 0.507, p < .001). At 36 months, posttraumatic stress symptoms were independently predicted by posttraumatic symptom levels at 12 months and depressed mood during admission (R(2) = 0.635, p < .001). CONCLUSION: Posttraumatic stress symptoms persist for at least 3 years after an acute cardiac event. Early emotional responses are important in predicting longer-term posttraumatic stress. It is important to identify patients at risk for posttraumatic stress as they are more likely to experience reduced quality of life.

Social networks and partner stress as predictors of adherence to medication, rehabilitation attendance, and quality of life following acute coronary syndrome.

OBJECTIVE: This study examined whether social network size and partner stress predicted medication adherence, cardiac rehabilitation attendance, and quality of life 12 months following hospitalization for an acute coronary syndrome (ACS). DESIGN: ACS patients (N = 193, M age = 60.6 years, SD = 11.4 years, 23% female) were recruited shortly following admission to 4 local hospitals. A prospective design was employed with follow-up data collected 12 months following hospital admission. MAIN OUTCOME MEASURES: Data were gathered on social network size and partner stress. The main outcomes assessed at 12 months were medication adherence, cardiac rehabilitation attendance, and quality of life (Short Form 36). RESULTS: Partner stress predicted medication nonadherence, odds ratio: 2.89, (95% CI = 1.21, 6.95). ACS patients with large social networks were more likely to attend rehabilitation, odds ratio: 3.42, (95% CI = 1.42, 8.25). Analyses were adjusted for age, gender, clinical risk scores, readmission/recurrence, and negative affectivity. Both partner stress and smaller social network size were associated with poorer quality of life. CONCLUSION: Social network size and partner stress may partly exert their influence on coronary heart disease morbidity and mortality through recovery behaviors and maintenance of quality of life.

Cortisol awakening response is elevated in acute coronary syndrome patients with type-D personality.

OBJECTIVE: Type-D or "distressed" personality and depression following admission for acute coronary syndrome (ACS) have been associated with poor clinical outcome. The biological pathways underpinning this relationship may include disruption of the hypothalamic-pituitary-adrenocortical (HPA) axis. We therefore assessed cortisol output in patients who had recently suffered from ACS. METHOD: Salivary cortisol was assessed eight times over a 24-h period in 72 patients within 5 days of admission for ACS. Depressive symptoms were measured with the Beck Depression Inventory (BDI), and type-D personality was measured with the Type-D Scale-16. Particular attention was given to cortisol awakening response (CAR), which was measured as the difference in cortisol between waking and peak responses 15-30 min later. RESULTS: Cortisol showed a typical diurnal pattern, with low levels in the evening, high levels early in the day, and CAR averaging 7.58+/-10.0 nmol/l. Cortisol was not related to the severity of ACS or underlying coronary artery disease or to BDI scores. The CAR was positively associated with type-D personality independently of age, gender, and body mass (P=.007). Linear regression showed that type-D personality accounted for 7.9% of the variance in CAR after age, sex, body mass, BDI, cortisol level on waking, and fatigue had been taken into account (P=.008). CONCLUSIONS: Type-D personality may be associated with disruption of HPA axis function in survivors of acute cardiac events and may contribute to heightened inflammatory responses influencing future cardiac morbidity.

Psychological and clinical predictors of return to work after acute coronary syndrome.

AIMS: Resumption of paid employment following acute coronary syndrome (ACS) is an important indicator of recovery, but has not been studied extensively in the modern era of acute patient care. METHODS AND RESULTS: A total of 126 patients who had worked before hospitalization for ACS were studied with measures of previous clinical history, ACS type and severity, clinical management, and sociodemographic characteristics. Depressed mood (Beck Depression Inventory) and type D personality were measured 7-10 days following admission. Among them, 101 (80.2%) had returned to work 12-13 months later. Failure to resume work was associated with cardiac factors on admission (heart failure, arrhythmia), cardiac complications during the intervening months, and depression scores during hospitalization. It was not related to age, gender, socioeconomic status, type of ACS, cardiac history, acute clinical management, or type D personality. In multivariate analysis, the likelihood of returning to work was negatively associated with depression, independently of clinical and demographic factors [adjusted odds ratio 0.90, CI 0.82-0.99, P=0.032]. CONCLUSION: Depressed mood measured soon after admission is a predictor of returning to work following ACS. The management of early depressed mood might promote the resumption of economic activity and enhance the quality of life of cardiac patients.

Patients' beliefs about the causes of heart disease: relationships with risk factors, sex and socio-economic status.

BACKGROUND: Patients' beliefs about the causes of their heart disease (causal attributions) are important to effective medical communication, psychological adaptation, and adherence to advice. We assessed the extent to which causal attributions relate to risk factors, sex and socio-economic status in men and women diagnosed with acute coronary syndrome. DESIGN: We conducted an interview and questionnaire study of 171 acute coronary syndrome patients assessed within 5 days of admission to three hospitals in the London area. METHOD: Patients rated beliefs in the role of 16 factors in causing their heart disease. Associations between attributions and risk factors were assessed, and differences in beliefs by sex and socio-economic status (defined by educational attainment) analysed. RESULTS: The most common attributions were to stress, smoking, high blood pressure, chance or bad luck, and heredity. Attributions were strongly associated with risk factors: 90% of smokers attributed heart disease to smoking, compared with 0% never smokers; 90.4% of hypertensives attributed heart disease to high blood pressure, 72.2% of patients with a positive family history to heredity, 85% of obese patients to being overweight, and 49% of sedentary patients to lack of exercise. Attributions to stress were related both to current mood and reports of recent life stress. There were few sex differences, but higher socio-economic status patients were more likely to attribute heart disease to heredity and genetic factors. CONCLUSIONS: Causal beliefs about heart disease are strongly associated with risk factors. Effective communication about modifiable risk factors may influence causal beliefs and stimulate lifestyle change, thereby promoting secondary prevention.